A Brain-Dead Mother, a Million-Dollar Baby
The case of a pregnant woman in Texas kept on life support against her family's wishes has captured the nation's attention as ethical debates swirl, but there is another compelling aspect to this story: The fetus she is carrying may be the first real million-dollar baby.
Marlise Munoz, 33, has been on life support at John Peter Smith Hospital in Fort Worth, Texas, since late November, when she was declared brain dead following oxygen deprivation related to a possible blood clot in her lungs. The patient's medical details have not been released.
At the time of her legal death, she was 14 weeks pregnant. Her advanced directive, and the wishes of her husband and family, call for removal from life support. However, Texas law prohibits removing life support from pregnant women.
So what will this extended hospital stay cost?
Medical ventilation can run $1,500 per day, according to a 2005 study, and long-term ICU can run about $5,000 per day. But Munoz's unique situation could mean even higher costs, said Adam C. Powell, PhD, a healthcare economist at Payer+Provider in Boston.
At $5,000 per day, Munoz's hospital bills would be $350,000 after 70 days, or 24 weeks into her pregnancy, when the baby would have about a 50% chance of survival. By the time she reaches 112 days, at which point she would be 30 weeks pregnant, the bill would be $560,000, and the baby would have more than a 92% chance of survival.
Then there's the cost of a C-section, roughly $4,500 for physicians' fees alone, according to the Healthcare Blue Book.
Once the child is born, Brian S. Carter, MD, a neonatologist at Children's Mercy Hospital in Kansas City, Mo., told MedPage Today that the neonate could spend anywhere between 2 to 4 months in the neonatal intensive care unit (NICU), depending upon how many weeks he or she is premature.
NICU costs generally run more than $3,500 per day. After 2 months, the NICU bill would be roughly $210,000, and by 4 months, it could reach $420,000. Carter suggested the baby would spend roughly 2 months in the NICU if the birth occurred at 28 weeks, but it would look more like 4 months if the birth was closer to 24 weeks.
That means a grand hospital bill total of anywhere from $439,500 to $984,500.
Powell suggested that the cost the family will have to shoulder will depend on their coverage. "In the worst case scenario, the family gets hit with the maximum out-of-pocket," he said. It's unclear how much that would be, but it's very unlikely they would face more than a fraction of the total cost. Insurance coverage for a woman that has been declared brain dead is a gray area, Powell said.
Munoz was a paramedic and her husband is a firefighter. The fact that Munoz worked -- presumably for more than 18 months -- means the child will be eligible for Social Security death benefits until the age of 18. Her salary is unknown, but if it were $45,000 per year, the combination of payments to her husband and their child would be about $3,000 per month. That's $36,000 per year for 18 years or a total of $648,000.
Taken together, even a conservative estimate of the costs exceeds $1 million, and could be more than $1.6 million.
The Clinical Outlook
Keeping the mother's body stable and avoiding life-support-related infections throughout the pregnancy will be the key to a good fetal outcome, say clinicians, but there is considerable risk for brain damage from the initial injury.
R. Phillips Heine, MD, Director of Maternal-Fetal Medicine at Duke Medical Center, told MedPage Today that as long as providers are able to keep Munoz stable (e.g., no further blood clots or bed sores, quality perfusion and oxygen levels), "the risk of continuing therapy is probably pretty minimal to the infant."
Mona Prasad, DO, MPH, a maternal-fetal medicine specialist at the Ohio State University Wexner Medical Center, speculated that the course of delivery would most likely involve a C-section, and that the timing of delivery would depend on how well the intrauterine environment could be controlled.
Prasad believes that the greatest risk to a mother on life-support would be infection. "The most quantifiable risk is that associated with a ventilator -- pneumonia in the mother. A mother on life support will also likely have a lot of lines and tubes that will increase the risk of infection and put the baby at risk."
Prasad noted that if the providers were to determine that the NICU environment could provide more stability than the womb, a pre-term birth might be the best course of action.
Carter told MedPage Today that the medications given to Munoz in the emergency department to resuscitate her would also have benefited the fetus. But, that the impact of the maternal incident itself is what poses the greatest risk.
"As we consider the impact of maternal illness, or an arrest, or episode of significant shock at 14 weeks, it's the fact that the fetus in utero also suffered the same phenomenon," Carter said.
Carter said the infant is at high risk of cerebral palsy.
Heine agreed. "The real issue has to do with the event that caused her to go on life support. That damage is really hard to predict. We think that 80% to 90% of all cases of cerebral palsy are due to in utero events."
"About 20% of cardiac output goes to the utero-placental unit and serves the fetus, so a maternal event such as has been described for this woman can't help but impact the fetal development in a negative fashion, and I would be very concerned about the impact that it has specifically on fetal brain development," Carter said.
The Ethical Debate
Several ethicists question the humanity of keeping a brain dead woman on life support against the family's wishes; however, others believe that protecting what is technically a viable fetus is the humane course.
George Annas, JD, MPH, Chair of the Department of Health Law, Bioethics, and Human Rights at Boston University School of Public Health, told MedPage Today, "The law cannot answer this case with a blunt always/never rule. Patient autonomy and medical ethics should guide such tragic and inherently difficult decisions."
Professor William M. Sage, MD, JD, Vice Provost of Health Affairs at the University of Texas School of Law, told MedPage Today he also questioned the intention and application of the law in this case. "The hospital claims it is complying with Texas law."
"I doubt the law applies to a deceased woman who was pregnant at the time of her death," Sage said.
"As an ethical matter, this case is unusual because the family seems to be asserting that the mother would not have wanted care to be given to the fetus after her death, but the hospital refuses to honor that choice," Sage continued.
Annas agreed, "Extraordinary means to preserve the life of a nonviable fetus against the wishes of the family should probably never be used, at least not longer than a few days, and then only if a healthy infant is the probable result."
"The issue is much more difficult when the pregnant woman is dead, because the dead have no constitutional rights and no claim to liberty or autonomy. They do, however, have a "right" to have their dead bodies treated with respect, and this, I think, should limit the time that physicians can use their dead body against their likely wishes," Annas said.
"There is a pretty robust legal and ethical consensus around the right of a patient, or their representative, to refuse medical care," Alan Regenberg, MBe, of Johns Hopkins Berman Institute of Bioethics, told MedPage Today.
"The law is intended to protect the uncertain interests of a fetus. These interests can only be protected in cases such as this by violating the patient's rights. The law itself is ethically problematic -- it puts hospitals into the unfortunate position of having to choose between violating this law or violating their patients' rights," Regenberg said.
According to Tia Powell, MD, director of Montefiore Einstein Center for Bioethics, the providers are misinterpreting the law altogether, she told MedPage Today. "No law requires any medical treatment for a dead person. If, as is alleged, the hospital knows this person meets criteria for brain death and they have failed to document this in the chart, then, yes, I believe they have behaved unethically."
"A judge should intervene to require an examination of the patient to determine whether or not she meets criteria for brain death," Powell recommended.
Even if Munoz had an iron-clad advanced directive prior to her health incident, she did not have one updated after knowledge of her pregnancy, rendering the directive unusable under the circumstances, said Texas Medical Association spokesperson Robert Tenery, MD.
"The fetus was deemed viable at the time of admission," Tenery, former chair of the American Medical Association's Council on Ethical and Judicial Affairs, told MedPage Today. As there is no way to know about brain damage at that stage, viability was determined via heartbeat, which was strong enough to thwart decisions to remove life support.
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